Endoscopic nasal palatoplasty

ABSTRACT

The endoscopic nasal palatoplasty procedure provides a reduction in the posterior aspect of the soft palate and/or uvula, thereby increasing the area of the nasopharyngeal passage between the soft palate and/or uvula and the back of the nasopharynx. This increased nasopharyngeal area promotes nasal breathing, thereby reducing reliance upon oral breathing and corresponding sleep-disordered breathing syndrome and associated problems such as sleep apnea and snoring. The procedure is performed using a conventional surgical implement, such as a Coblator® or other electro cauterizing or laser cauterizing implement, to ablate and cauterize a series of lesions in the soft palate and/or uvula. The procedure is performed by inserting the surgical implement through one of the nasal passages to access the superior surface of the soft palate and/or uvula.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates generally to methods and surgicalprocedures for treating sleep-disordered breathing, and particularly toan endoscopic nasal palatoplasty procedure using an instrument insertedendonasally to perform procedures on the soft palate and/or uvula.

2. Description of the Related Art

Various breathing problems are well known to result in correspondingdifficulties in sleep, including snoring, sleep apnea, restless sleepand corresponding daytime somnolence. These various problems are notonly difficult for the subject, but for the sleeping partner of thesubject as well. Reduced oxygenation due to breathing interruptionduring more severe episodes is particularly problematic, and extremecases have been known to result in hypertension, cardiac arrhythmia, andeven death due to breathing cessation during apnea.

The physical causes of the above problems are reasonably wellunderstood, ranging from nasal turbinate hypertrophy to lingual andmaxillary displacement to a narrowing of the pharynx due to partialobstruction by the soft palate and/or uvula. The latter syndrome isparticularly likely when the soft palate and/or uvula are more flaccidthan normal. Oral breathing to overcome this, particularly during sleep,tends to result in inferior and/or posterior displacement of themandible and the base of the tongue, thereby exacerbating the problem.

Accordingly, a number of treatments have been developed over the years.Generally, less invasive treatments are attempted initially, e.g.,continuous positive airway pressure (CPAP). However, when such treatmentis ineffective, surgical treatment is often called for. Such surgicaltreatment may comprise one or more of a large number of differentprocedures, including septoplasty, turbinoplasty, tonsillectomy and/oradenoidectomy, uvulopalatopharyngoplasty, and/or possibly otherprocedures.

One such procedure comprises modification of the soft palate and/oruvula to stiffen these organs and to reduce their posteriordisplacement. This has been conventionally accomplished in the past bymeans of the placement of small implants in the soft palate, or bycauterizing or ablating the soft palate and/or uvula tissue to producescarring of those tissues and to reduce their flaccidity. This may alsoresult in some reduction in the size and/or posterior extension of theseorgans. These surgical procedures have been accomplished conventionallyby accessing the interior surface(s) of the soft palate and/or uvulathrough the mouth of the patient. The problem with accessing thesestructures orally is that the treatment is applied to the inferiorsurfaces of the organs, thus tending in many cases to draw the softpalate and/or uvula downward. This oral access technique may also resultin some destruction of the oral mucosa, which is not desirable.

Thus, an endoscopic nasal palatoplasty procedure solving theaforementioned problems is desired.

SUMMARY OF THE INVENTION

The endoscopic nasal palatoplasty operation or procedure provides asurgical correction of the soft palate and/or uvula, resulting in someanterior displacement to at least the posterior portions of these organsdue to tissue shrinkage after treatment. This opens up thenasopharyngeal region to promote nasal breathing and reduce oralbreathing, thereby reducing snoring, sleep apnea, and othersleep-disordered breathing problems. However, rather than accessing theinferior surfaces of the soft palate and uvula through the mouth, thepresent endoscopic nasal palatoplasty procedure accesses the superiorsurface(s) of the soft palate and/or uvula by means of one of the nasalpassages of the patient. The lesions formed by this surgery tend to drawthe posterior portions of the soft palate and/or uvula forward, therebyincreasing the size of the nasopharyngeal passage. The flaccidity of thesoft palate and/or uvula are also reduced, thus increasing theirresistance to oral airflow that might otherwise deflect them toward thenasal air passage to promote oral breathing.

Various surgical tools or implements may be used to perform theendoscopic nasal palatoplasty of the present invention, as desired. Apreferred implement is a Coblator® (“coblator” is a registered trademarkof ArthroCare Corporation of Austin, Tex.), a surgical instrumentproduced by ArthroCare® ENT of Sunnyvale, Calif. The Coblator® is adual-function implement. The extreme distal tip of the instrumentproduces a plasma that ablates the tissue into which the tip isinserted, thereby forming a channel in the tissue. Another elementdisplaced from the extreme distal tip creates heat that results incoagulation of the ablative lesion to complete the treatment. Othersurgical implements may be used in lieu of the Coblator®, e.g., anelectro cauterizing implement, laser cauterizing implement, or othersimilar device. The endoscopic nasal palatoplasty procedure may beperformed as a stand-alone procedure, or along with other relatedconventional surgical procedures, such as septoplasty and/orturbinoplasty during the same operating session.

The penetration of the instrument tip substantially through thethickness of the soft palate and/or uvula results in the organs drawingor shrinking generally uniformly in an anterior direction, therebyincreasing the space between the posterior surface of the uvula and theback of the nasopharyngeal passage to encourage nasal breathing andreduce oral breathing. This reduction in oral breathing produces acorresponding reduction in sleep-disordered breathing syndrome, thusproviding relief for the patient and his or her sleep partner.

These and other features of the present invention will become readilyapparent upon further review of the following specification middrawings.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a prior art diagrammatic view of the anatomy of the lowerportion of the human head, illustrating an exemplary restricted airwaygap to be treated by the endoscopic nasal palatoplasty procedureaccording to the present invention.

FIG. 2 is a diagrammatic view of the anatomy of the lower portion of thehuman head similar to FIG. 1, illustrating the placement of a surgicalimplement through one of the nasal passages to access the superiorsurface of the soft palate and/or uvula for performing the endoscopicnasal palatoplasty procedure of the present invention to relieve theobstruction of FIG. 1.

FIG. 3 is a diagrammatic view in section of the anatomy of the lowerportion of the human head similar to FIGS. 1 and 2, illustrating thewidened airway gap between the soft palate and uvula and the back of thethroat after the endoscopic nasal palatoplasty procedure of the presentinvention.

FIG. 4 is a flowchart briefly describing the steps of a method ofperforming an endoscopic nasal palatoplasty according to the presentinvention.

Similar reference characters denote corresponding features consistentlythroughout the attached drawings.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

The endoscopic nasal palatoplasty is a surgical procedure adapted totreat the soft palate and/or uvula to promote their forward contracture,thereby further opening the space between the posterior portion of theuvula and the nasopharynx. The operation or procedure is adapted totreat the superior or upper surfaces of the soft palate and/or uvula,rather than the lower or inferior surfaces, as is conventionally done.The procedure may be performed under local anesthetic and/or on anoutpatient or office treatment basis, depending upon the specific numberof procedures to be performed and the judgment of the surgeon.

FIG. 1 of the drawings is a prior art diagrammatic view of the anatomyof the lower and forward portion of an exemplary human head H having areduced nasopharyngeal passage NP due to the posterior displacement ofthe soft palate SP and/or uvula U. The reduction in the area of thenasopharyngeal passage NP results in restricted airflow through the noseand corresponding greater airflow through the mouth, particularly duringsleep. The oral airflow often results in vibration of the soft palateand/or uvula during sleep, i.e., snoring and other sleep relatedproblems. Oral breathing may also result in various other problems,e.g., posterior displacement of the base of the tongue, inferiormandibular displacement, etc., all of which exacerbate sleep problems.

FIG. 2 of the drawings illustrates treatment of the soft palate SP byendoscopic nasal palatoplasty. FIG. 4 provides a flowchart brieflydescribing the steps in the method of carrying out the endoscopic nasalpalatoplasty. The patient is initially prepared for the operation orsurgical procedure in the conventional manner, generally as indicated inthe first step 100 of FIG. 4. The specific steps involved in thepreparation will depend upon the specific surgical procedures to beperformed. For example, it may have been determined that the patientneeds other surgery in addition to the endoscopic nasal palatoplastyprocedure, such as septoplasty and/or some form of turbinoplasticprocedure.

The appropriate surgical implements will be prepared for surgery, thespecific surgical implements also depending upon the specific surgicalprocedure or procedures to be performed. In the case of the endoscopicnasal palatoplasty procedure, the preferred endoscopic surgicalinstrument or implement is the Coblator®, an electrical surgicalimplement manufactured by ArthroCare® ENT of Sunnyvale, Calif. TheCoblator® is capable of producing a plasma field around the tip of thewand by generating radio frequency mediated through a fluid, such assaline, thereby ablating the surrounding tissue when inserted therein.Lower power may be provided to the device to produce coagulation of thelesion formed, if desired. Other conventional electrical and/orelectronic surgical implements or instruments producing coagulationand/or cauterization may be used in lieu of the Coblator®, e.g., electrothermal and laser surgical implements.

When the patient and the instrument or instruments have been readied inaccordance with the surgical procedure or procedures to be performed,the surgical procedure or procedures are performed. In many cases it maybe necessary to perform some other surgical procedure or proceduresprior to the endoscopic nasal palatoplasty procedure, e.g., septoplastyto correct the position of the nasal septum and/or turbinoplasty tocorrect some aspect of the nasal turbinates. These additional operationsor procedures are indicated in the optional second step 102 of theflowchart of FIG. 4, as they will not be required in every instance.

At this point, the endoscopic nasal palatoplasty procedure is performed.As the name of the procedure indicates, the endoscopic implement 10(e.g., Coblator®, etc.) is inserted through one of the nasal passages Nof the patient and the distal tip of the wand 12 is positioned asdesired. (Various other procedures are performed prior to insertion ofthe wand, e.g., treating the tip of the wand with a saline solution forbetter electro conductivity, but such procedures are conventional in theuse of the device.) The drawing of FIG. 2 illustrates an exemplaryprocedure in which the distal tip of the wand 12 is repeatedly insertedinto the superior surface of the soft palate SP to form a series oflesions 14. When a plasma-forming implement, such as the Coblator®, isused, each insertion and activation of the device results in theablation of immediately adjacent tissue and formation of a small channelin the tissue at each penetration as a result of the plasma dischargewithin the tissue. Other electrical surgical implements may coagulateand/or cauterize the tissue, so that the end result is contracture ofthe treated tissue toward the area treated due to the necrosis andfibrosis resulting from the surgical treatment. This also results inreduction in the extent or size of the treated tissue or organ and astiffening of the treated organ, thereby reducing the flaccidity of thetissue and enlarging the nasopharyngeal passage.

The distal tip of the wand 12 is inserted into the tissue for a depth onthe order of one centimeter in accordance with the judgment of thesurgeon, and the distal tip of the wand 12 is charged electrically for aperiod of about five to ten seconds, again in accordance with thejudgment of the surgeon. The depth of penetration of the distal tip ofthe wand 12 and the duration of application are conventional steps inthe method of using the Coblator® or other electrical surgicalimplement.

The treatment is repeated a plurality of times, in accordance with thejudgment of the surgeon, as indicated by the completed lesions 14 formedin the superior surface of the soft palate SP, indicated by the smalldots shown on that surface in FIG. 2. The penetrations of the superiorsurface of the soft palate SP are preferably carried out according to apredetermined plan or pattern. Preferably, a series of four to five suchlesions are formed in a lateral row to each side of the soft palate SP,i.e., a total of eight to ten lesions per row, with multiple rows beingformed and extending posteriorly from the juncture of the soft palate SPwith the hard palate HP to the uvula U. (It will be noted that thesurgical implement is removed and inserted through either nostril Naccording to the side of the soft palate SP upon which the treatment isbeing performed, during the duration of the procedure.) This part of theprocedure is indicated generally by the fourth step 106 of the flowchartof FIG. 4.

In many instances, similar treatment of the superior surface of theuvula U may be indicated in lieu of or in addition to treatment of thesuperior surface of the soft palate SP described above. This may beaccomplished in a similar manner to the procedure described above fortreatment of the soft palate SP, i.e., preparation of the surgicalimplement as required, insertion of the wand of the implement througheither nasal passage of the patient depending upon the lateral aspect ofthe uvula to be treated (both sides will typically be treatedsymmetrically, the surgical implement being removed and reinsertedthrough the appropriate nasal passage), and penetration and electricalactivation of the wand of the implement in accordance with the judgmentof the surgeon. The result is the formation of a series of uvularlesions 16 on the superior surface of the uvula U, generally asindicated in FIG. 2 of the drawings. The resulting necrosis and fibrosisresults in reduction in the extent or size of the treated tissue ororgan and a stiffening of the uvula, thereby reducing the flaccidity ofthe tissue and enlarging the nasopharyngeal passage.

When the surgical procedure on the superior surface of the soft palateSP and/or uvula U has been completed, the surgical implement 10 with itswand 12 is withdrawn from the nasal passage NP of the patient and thepatient is monitored during recovery, generally as indicated by thefifth and sixth steps 108 and 110 of the flowchart of FIG. 4. Thevarious lesions 14 and/or 16 formed in the superior surfaces of the softpalate SP and/or uvula U in accordance with the procedure result incontraction and stiffening of the treated tissues or organs, as notedfurther above. The contracted soft palate and/or uvular tissues resultin the enlargement of the nasopharyngeal passage, as indicated by theenlarged passage NP2 shown in FIG. 4, which represents the affectedareas after treatment.

The increased area of the enlarged nasopharyngeal passage NP2, alongwith the reduction in flaccidity of the treated soft palate SP and/oruvula U, greatly enhance nasal aspiration and greatly reduce oreliminate vibration of the subject tissues, particularly during sleep,thereby providing greater comfort and freer breathing during sleep forthe treated patient. Moreover, accessing the soft palate and/or uvulathrough the nasal passages obviates the need for an oral procedure whereother nasal procedures (e.g., septoplasty and turbinoplasty) are alsoperformed, thus leaving the oral passage intact during the healing ofthe nasal and/or superior surfaces of the soft palate and/or uvula andobviating disturbance or damage to the oral mucosa during the operatingprocedure.

It is to be understood that the present invention is not limited to theembodiments described above, but encompasses any and all embodimentswithin the scope of the following claims.

1. A method of performing an endoscopic nasal palatoplasty procedure,comprising the steps of: (a) providing at least one electric endoscopicsurgical implement having a distal tip; (b) preparing the patient andsurgical implement for the procedure; (c) inserting the surgicalimplement through one of the nasal passages of the patient; (d)penetrating the superior surface of the soft palate of the patient at apredetermined location and to a predetermined depth using the distal tipof the surgical implement; (e) electrically actuating the surgicalimplement, thereby forming a lesion in the soft palate of the patient;(f) repeating steps (d) and (c) a plurality of times in a predeterminedpattern; (g) withdrawing the surgical implement from the nasal passageof the patient; and (h) monitoring the recovery of the patient.
 2. Themethod of performing an endoscopic nasal palatoplasty procedureaccording to claim 1, further comprising the steps of: (a) penetratingthe superior surface of the uvula of the patient at a predeterminedlocation and to a predetermined depth using the distal tip of thesurgical implement; and (b) electrically actuating the surgicalimplement, thereby forming a lesion in the uvula of the patient.
 3. Themethod of performing an endoscopic nasal palatoplasty procedureaccording to claim 1, further comprising the step of initiallyperforming at least one operation selected from the group of operationsconsisting of turbinectomies and septoplasties.
 4. The method ofperforming an endoscopic nasal palatoplasty procedure according to claim1, wherein the step of electrically actuating the surgical implement andforming a lesion in the soft palate of the patient comprises using asurgical implement generating a plasma, the plasma ablating the tissue.5. The method of performing an endoscopic nasal palatoplasty procedureaccording to the method of claim 1, wherein the step of electricallyactuating the surgical implement and forming a lesion in the soft palateof the patient comprises using an electrocautery needle.
 6. The methodof performing an endoscopic nasal palatoplasty procedure according tothe method of claim 1, wherein the step of electrically actuating thesurgical implement and forming a lesion in the soft palate of thepatient comprises using an electro thermal surgical implement andthermally cauterizing the tissue.
 7. The method of performing anendoscopic nasal palatoplasty procedure according to the method of claim1, wherein the step of electrically actuating the surgical implement andforming a lesion in the soft palate of the patient comprises using alaser probe and thermally cauterizing the tissue.
 8. A method ofperforming an endoscopic nasal palatoplasty procedure, comprising thesteps of (a) providing at least one electric endoscopic surgicalimplement having a distal tip; (b) preparing the patient and surgicalimplement for the procedure; (c) inserting the surgical implementthrough one of the nasal passages of the patient; (d) penetrating thesuperior surface of the uvula of the patient at a predetermined locationand to a predetermined depth using the distal tip of the surgicalimplement; (e) electrically actuating the surgical implement, therebyforming a lesion in the uvula of the patient; (f) repeating steps (d)and (e) a plurality of times, in a predetermined pattern; (g)withdrawing the surgical implement from the nasal passage of thepatient; and (h) monitoring the recovery of the patient.
 9. The methodof performing an endoscopic nasal palatoplasty procedure according tothe method of claim 8, further comprising the steps of: (a) penetratingthe superior surface of the soft palate of the patient at apredetermined location and to a predetermined depth using the distal tipof the surgical implement; and (b) electrically actuating the surgicalimplement, thereby forming a lesion in the soft palate of patient. 10.The method of performing an endoscopic nasal palatoplasty procedureaccording to the method of claim 8, further comprising the step ofinitially performing at least one operation selected from the group ofoperations consisting of turbinoctomies and septoplasties.
 11. Themethod of performing an endoscopic nasal palatoplasty procedureaccording to the method of claim 8, wherein the step of electricallyactuating the surgical implement and forming a lesion in the soft palateof the patient comprises using a surgical implement generating a plasma,the plasma ablating the tissue.
 12. The method of performing anendoscopic nasal palatoplasty procedure according to the method of claim8, wherein the step of electrically actuating the surgical implement andforming a lesion in the soft palate of the patient comprises using anelectrocautery needle.
 13. The method of performing an endoscopic nasalpalatoplasty procedure according to the method of claim 8, wherein thestep of electrically actuating the surgical implement and forming alesion in the soft palate of the patient comprises using an electrothermal surgical implement and thermally cauterizing the tissue.
 14. Themethod of performing an endoscopic nasal palatoplasty procedureaccording to the method of claim 8, wherein the step of electricallyactuating the surgical implement and forming a lesion in the soft palateof the patient comprises using a laser probe and thermally cauterizingthe tissue.
 15. A method of performing an endoscopic nasal palatoplastyprocedure, comprising the steps of: (a) providing at least one electricendoscopic surgical implement having a distal tip; (b) preparing thepatient and surgical implement for the procedure; (c) performing atleast one operation selected from the group of operations consisting ofturbinoctomies and septoplasties; (d) inserting the surgical implementthrough one of the nasal passages of the patient; (e) penetrating thesuperior surface of the soft palate of the patient at a predeterminedlocation and to a predetermined depth using the distal tip of thesurgical implement; (f) electrically actuating the surgical implement,thereby forming a lesion in the soft palate; (g) repeating steps (f) and(g) a plurality of times in a predetermined pattern; (h) optionally,performing steps (e) through (g) on the patient's uvula; (i) withdrawingthe surgical implement from the nasal passage of the patient; and (j)monitoring the recovery of the patient.
 16. The method of performing anendoscopic nasal palatoplasty procedure according to the method of claim15, wherein the step of electrically actuating the surgical implementand forming a lesion in the soft palate of the patient comprises using asurgical implement generating a plasma, the plasma ablating the tissue.17. The method of performing an endoscopic nasal palatoplasty procedureaccording to the method of claim 15, wherein the step of electricallyactuating the surgical implement and forming a lesion in the soft palateof the patient comprises using an electrocautery needle.
 18. The methodof performing an endoscopic nasal palatoplasty procedure according tothe method of claim 15, wherein the step of electrically actuating thesurgical implement and forming a lesion in the soft palate of thepatient comprises using an electro thermal surgical implement andthermally cauterizing the tissue.
 19. The method of performing anendoscopic nasal palatoplasty procedure according to the method of claim15, wherein the step of electrically actuating the surgical it implementand forming a lesion in the soft palate of the patient comprises using alaser probe and thermally cauterizing the tissue.